The Good Clinical Nursing Educator and the Baccalaureate Nursing
Clinical Experience: Attributes and Praxis
Karla J. Hanson, MS, RN; and Thomas E. Stenvig, PhD, RN, CNAA
AbstrAct
clinical education accounts for a significant portion of baccalaure-ate nursing (BsN) education. This study examined recent BsN program graduates’ views about clinical nurs-ing educator attributes that enhance the ability of the graduates to provide safe, effective patient care. in this de-scriptive study, 6 participants were interviewed using grounded theory techniques. The study framework blended the elements of cognitive field theory, the humanistic philosophy of teaching and learning, the gestalt theory of learning, and hergenhahn’s behavioral change model. Partici-pants identified three attributes of a good clinical nursing educator: knowl-edge, interpersonal presentation, and teaching strategies. analysis revealed that educator attributes and phases of the clinical experience process to-gether form the foundation for clini-cal experience praxis. educators can improve the clinical education experi-ence by developing teaching strate-gies and evaluation tools that build
on the positive attributes and phases of the clinical experience identified in this study.
P
lanned clinical experiences should constitute a large part of baccalaureate nursing stu-dent (BsN) education, as outlined in the american association of colleges of Nursing’s Essentials ofBaccalaure-ate Education for Professional Nurs-ing Practice (1998). BuildNurs-ing on the
foundation of a liberal education, the baccalaureate professional nursing curriculum uses both course work and clinical experiences to instill pro-fessional values, develop core compe-tencies and knowledge, and broaden understanding of beginning practi-tioners’ roles. student learning and performance in clinical experiences reflect the educator’s ability to create an environment in which the student can learn (Reilly & Oermann, 1992). The purpose of this study was to identify good clinical nursing educa-tor attributes, as perceived by recent BsN program graduates. Good clini-cal educator attributes included those that best prepared graduates for safe, effective nursing practice.
background
several studies have identified good nursing faculty clinical educator attributes (Gignac-caille & Oermann, 2001; Kotzabassaki et al., 1997; Li, 1997; Mogan & Knox, 1987; Nehring, 1990; sieh & Bell, 1994). Knox and Mogan (1985) developed the Nursing clinical Teacher effectiveness inventory (NcTei)
to identify good clinical educator attributes. The NcTei identified 5 categories of attributes for a good clinical nursing educator: teaching, nursing, evaluation, interpersonal relationships, and personality. Nursing students, educators, and graduates rated evaluation as highest and personality as lowest in importance.
showing respect for students has consistently been identified as a posi-tive clinical educator attribute (Berg-man & Gaitskill, 1990; Daniels & De-Vos, 1996; Gignac-caille & Oermann, 2001; Kotzabassaki et al., 1997; Li, 1997; Mogan & Knox, 1987; Nehring, 1990; sieh & Bell, 1994), as was giv-ing objective evaluations and positive feedback to students (Benor & Levi-yof, 1997; Bergman & Gaitskill, 1990; flagler, Loper-Powers, & spitzer, 1988; Jacobson, 1966; Knox & Mogan, 1985; O’shea & Parsons, 1979). The clinical educator’s knowledge and display of professional competence has also been identified as important (Benor & Leviyof, 1997; Brown, 1981; Gignac-caille & Oermann, 2001; Johnsen, aasgaard, Wahl, & salmin-en, 2002; Knox & Mogan, 1985; Kotza-bassaki et al., 1997; Nehring, 1990; sieh & Bell, 1994). Johnsen et al. (2002) and Jacobson (1966) described the importance of teaching and nurs-ing competence as clinical educator attributes. Role model efficacy was perceived as an important attribute (Li, 1997; Nehring, 1990; O’shea & Parsons, 1979; Rauen, 1974; sieh & Bell, 1994; Wiseman, 1994). Gillespie (2002) emphasized the value of the student-teacher connection and bond-ing in the clinical settbond-ing.
Received: February 28, 2006 Accepted: December 7, 2006
Ms. Hanson is Instructor, and Dr. Stenvig is Associate Professor, South Dakota State University, College of Nursing, Brookings, South Dakota.
The authors acknowledge the assis-tance of Dr. Tish Smyer, RN, and Ms. Jodi Ness, MS, RN, with the data analysis for this study.
Address correspondence to Karla J. Han-son, MS, RN, Instructor, South Dakota State University, College of Nursing, P.O. Box 2275, SNF 209, Brookings, SD 57007-0098; e-mail: [email protected].
Many studies have used written questionnaires or evaluation forms for data collection to compare student and faculty views (Benor & Leviyof, 1997; Bergman & Gaitskill, 1990; Brown, 1981; flagler et al., 1988; Gignac-caille & Oermann, 2001; Johnsen et al., 2002; Knox & Mogan, 1985; Kotzabassaki et al., 1997; Li, 1997; Mogan & Knox, 1987; Nehring, 1990; O’shea & Parsons, 1979; Rauen, 1974; sieh & Bell, 1994; Wiseman, 1994). Wolf, Bender, Beitz, Wieland, and Vito (2004) used standardized course evaluation tools and content analysis of student written comments to identify strengths and weaknesses of faculty didactic and clinical teaching. Gillespie (2002) and Jacobson (1966) used a face-to-face group interview technique to collect data about student perceptions of clinical educator attributes. Only one study (Knox & Mogan, 1985) examined BsN program graduates exclusively to evaluate their perceptions of the clinical components of the educational experience.
several studies evaluated clinical educator attributes in other health disciplines. studies of medical stu-dents (Becker, Geer, hughes, & strauss, 1961) and radiation therapy students (Daniels & DeVos, 1996) found teaching competence, profes-sionalism, respect, and willingness to clarify expectations to be important clinical educator attributes.
Qualitative research using inter-view techniques to examine recent BsN program graduates’ preferred clinical educator attributes has been limited. in response, the research question for this study was, “What clinical educator attributes do recent baccalaureate degree nursing gradu-ates perceive as the attributes that ‘best’ prepared them to become nurs-es?”
Framework
The framework for this study is based on the cognitive field theory (Reilly & Oermann, 1992), the hu-manistic philosophy of teaching and learning (Pine & Boy, 1977), the ge-stalt theory of learning (Burns &
Grove, 2004), and hergenhahn’s (1988) behavioral change model. ele-ments of each of these were used in developing the research questions, designing the study approach using grounded theory methods, and com-paring study findings with results of earlier studies. On cognitive field theory, Reilly and Oermann (1992) stated, “The teacher can promote learning in the clinical setting or can discourage it; the teacher…becomes a significant variable in establishing a learning environment in the clinical area” (p. 140). Determining the best clinical educator attributes is para-mount.
The humanistic philosophy of teaching and learning enhances per-sonal growth in students by identify-ing environmental conditions neces-sary to facilitate learning (Pine & Boy, 1977). educators must view students as unique individuals and guide the learning experiences to meet their needs.
cognition, or gestalt thinking, is a critical element in the practice of competent nursing (Burns & Grove, 2004). Gestalt thinking allows the individual to look beyond old ways of thinking to apply newly learned prin-ciples. in gestalt thinking, learning occurs when experiences allow newly learned principles to be applied to both familiar and unfamiliar situa-tions.
in hergenhahn’s (1988) behavioral change model, learning is viewed as experiences leading to behavioral change. This model views learning on a lifelong continuum.
The blended framework used in this study reveals students have many varied opportunities to learn and experience the practice of nurs-ing. educators have the responsibility to teach students information, compe-tencies, professional values, and an understanding of the nursing role, in a caring, humanistic manner that will facilitate safe, effective practice.
Method
Recent BsN program graduates were interviewed, using grounded theory techniques, to determine the
perceived attributes that best pre-pared them as RNs. Open-ended in-terviews allowed an expansion on the data about the participants’ percep-tions of the clinical experience. Before potential participants were contacted, the study was approved by the agen-cy’s institutional review board. sample
The study’s target population con-sisted of recent BsN program gradu-ates. Recent graduates were assumed to have the necessary recall about clinical nursing education details. eligibility criteria were graduation from an accredited BsN program in the previous 6 to 18 months, current employment as an RN with bedside nursing and patient care responsi-bilities at the same facility for a mini-mum of 6 months, and willingness to be interviewed twice if requested by the principal investigator (K.J.h.).
Participants were recruited from the pool of graduates of two BsN programs in south Dakota. Names from graduation bulletins were cross-matched with names of RNs on Board of Nursing lists. invitation letters ex-plaining the study’s purpose, data col-lection procedures, eligibility criteria, and consent procedures were mailed to 65 potential participants with in-structions to contact the principal investigator. Three participants were identified through mailings, one par-ticipant was recruited through local announcements, and two additional participants were recruited through network sampling.
six participants (5 female, 1 male) were interviewed. ages ranged from 23 to 41 years (mean age = 29). all six participants graduated from the same university in eastern south Da-kota in 2002 or 2003. Three partici-pants graduated from an accelerated BsN program in which students who have a non-nursing baccalaureate degree complete the nursing curricu-lum in 12 months. The mean length of employment since graduation was 11.2 months.
Data collection and Analysis
after consent to audiorecord the interview was obtained, individual
face-to-face interviewing commenced. interviews included open-ended ques-tions asking participants to describe perceptions of clinical educator at-tributes and experiences. The first question was, “What is a good clinical educator to you?” Questions in later interviews were based on responses in previous interviews, as well as the interview in progress.
Data analysis followed ground-ed theory techniques describground-ed by strauss and corbin (1990): constant comparative analysis to evaluate the variation or similarity among data collected, open coding of raw inter-view data to identify main ideas or concepts, axial coding or the linking of open coding categories into more detailed subcategories, selective cod-ing for integration of data into refined categories, and data saturation or the accumulation of no new information. The principal investigator initially analyzed the data independently. Data were then analyzed by a review panel (composed of a doctorally pre-pared nurse with expertise in ground-ed theory research design and a grad-uate student conducting a qualitative research study) to assure auditability and reduce potential individual bias, enhance the identification of coding categories, and strengthen the validi-ty of findings. The review panel helped to revise questions for subsequent in-terviews and determine when data saturation had been achieved, which occurred after six interviews.
results
Positive clinical educator attribute categories revealed during data anal-ysis included educator knowledge, in-terpersonal presentation, and teach-ing strategies.
Educator Knowledge Attributes
Knowledge of Theory and Clinical Practice. educators’ current
knowl-edge in theory and clinical practice, and the integration of this knowledge into practice for students, was an important attribute. Reilly and Oer-mann (1992) discuss the importance of allowing opportunities for “prob-lem solving, experiential learning,
and human caring” (p. 48) in practice. One participant wanted a clinical ed-ucator who had a “good grasp of nurs-ing in general.” Three participants stressed the importance of realistic clinical assignments. One commented on the importance of “someone [who] can give you those experiences that are going to happen in real life.” This attribute is consistent with hergen-hahn’s (1988) model about student clinical experiences allowing stu-dents to learn and make behavioral changes.
Knowledge of the Facility.
aware-ness of how the clinical facility func-tions was an important attribute for clinical educators. One participant commented, “if your instructor’s lost [in the facility] there’s no hope for you.” Reilly and Oermann (1992) stressed the importance of clinical educators’ awareness of staff expectations for students, restrictions placed on stu-dents, facility resources, and student requirements prior to the experience. One participant stated, “When the in-structor doesn’t know the facility you can’t rely on your clinical instructor to help you through the day.”
Knowledge of the Students.
Knowl-edge of the students’ backgrounds and learning needs was identified as an attribute of a good clinical educator. Two accelerated BsN program gradu-ates’ comments were, “i want the in-structor to understand that i knew… more than some of the other people in my group” and “in the accelerated nursing program, i feel we have more focus, more direction.” This is consis-tent with Brookfield’s (1990) recom-mendation that educators be aware of student learning styles and readiness to learn before incorporating teaching styles for optimal learning. One par-ticipant believed “a clinical instructor should know her students and where they’re at, what they’re capable of doing, what they feel comfortable with.” students need to feel valued, respected, appreciated, and accepted as people (Pine & Boy, 1977).
Educator Interpersonal Presentation Attributes
Educator Attitude. Participants
identified a positive, professional,
and supportive attitude as an im-portant educator attribute. however, the definition of professionalism var-ied among participants. some of the phrases used to describe profession-alism include “not [being] intimidat-ing,” “guidintimidat-ing,” “a growing process,” and “[being] approachable.” Giving and receiving respect by facility staff, as well as students, were identified as important attributes of professional clinical educators. One participant stated, “it’s nice to be able to see clini-cal instructors [who] are certainly re-spected by the other nursing person-nel that we’re working with.” Reilly and Oermann (1992) discussed the need for educators to provide a car-ing atmosphere for learncar-ing. Becar-ing a good role model for students was de-scribed as a positive clinical educator attribute. Brookfield (1990) noted ed-ucator role modeling as a significant factor affecting student learning. a fairly equal balance in the amount of support and challenge offered to stu-dents will enhance the stustu-dents’ abil-ity to learn (Brookfield, 1990).
Encouraging Demeanor. cognitive
field theory supports problem solving as a dominant factor in clinical learn-ing (Reilly & Oermann, 1992). in the humanistic philosophy of teaching and learning, for learning to occur, educators should help students de-termine the significance behind spe-cific thoughts and ideas (Pine & Boy, 1977). all participants in this study identified the need for educators to en-courage student learning and expand students’ gestalt. One participant preferred “someone who is excited about the opportunities, always look-ing for an opportunity for the student to go further or see something.” The importance of encouraging, construc-tive feedback was mentioned by all 6 participants. The way educators pres-ent feedback influences how feedback is received by students.
Organizational Skills. a good
clini-cal educator’s organizational skills must influence both the clinical expe-rience and paperwork assignments. Brookfield (1990) claimed if educators do not make student expectations clear, it is more likely students will learn to mistrust educators and
re-sist the instruction. One participant stated, “it’s difficult doing the flip-flop between instructors and trying to know how i’m supposed to be acting out here [in a new clinical setting].” Without clear explanations, students have difficulty integrating new infor-mation into their current knowledge.
Serving as a Primary Resource. all
participants wanted clinical educa-tors to be approachable and accessi-ble as the students’ primary resource. One participant stated, “i want some-one who i can go and ask questions to because a lot of times the nurses are too busy.” another stated, “i want someone i think i can go to if i have a problem.” students depend on guid-ance from educators to learn. teaching strategies Attributes
Managing Paperwork. all
partici-pants indicated they felt overwhelmed by the amount of clinical course pa-perwork. One participant comment-ed, “students get bogged down with paperwork.” Participants preferred educators to limit paperwork to an amount conducive to learning and appropriate to patient care. Because the first 3 participants had similar interpretations, the remaining 3 par-ticipants were asked specifically how clinical paperwork could be adjusted to enhance learning.
four participants expected clini-cal educators to provide timely and constructive feedback on paperwork. “We’re expected to turn them in on a deadline. i think we should be able to expect that those get back to us [quickly].” feedback should encour-age further learning by students.
The relevance of paperwork in meeting clinical objectives also needs to be clear. Participants felt educators should make priorities known prior to the start of the clinical day. One ac-celerated program graduate felt pa-perwork was a part of meeting clini-cal objectives. a standard program graduate felt the educator should be able to compromise on the paperwork when the student had difficulty meet-ing clinical objectives and insufficient time to complete paperwork.
Keeping Students Challenged.
cog-nitive field theory (Reilly & Oermann,
1992) is based on using critical think-ing in the process of problem solvthink-ing. all participants identified stimulation of critical thinking through challenge in the clinical setting as an attribute helpful to the learning process. One participant stated it was beneficial to have “someone [who] can help you click all that information through.” The clinical educator has the opportu-nity to enhance learning by question-ing students and makquestion-ing them think critically about situations. One par-ticipant summed it up as, “someone who can get me to think on my own rather than just giving me the an-swer.” Brookfield (1990) claimed some of the most transformative learning opportunities are those that offer stu-dents the chance to challenge what is known.
Postconference Planning. as long
as the students’ needs were addressed, meeting for discussion and review af-ter clinical experiences had a positive effect on learning in the clinical set-ting. One participant commented, “i don’t think it [postconference] should be dropped because you need a sum-mary or a closing to the day.” Three participants preferred a structured, focused postconference.
Discussion
clinical Experience Praxis
During data analysis, investiga-tors identified the formation of a clini-cal experience praxis involving three phases in which the clinical educator prepares for the clinical experience, teaches the clinical experience itself, and evaluates the clinical experience. although preparation, teaching, and evaluation phases of the clinical ex-perience are commonly viewed dis-cretely and in a linear time line for planning purposes, this clinical expe-rience praxis emerged as a function of educators’ attributes and ability to manage the interplay of experiences during each phase. educators’ skill in facilitating student reflection and syn-thesis of this interplay across phases during the entire experience emerged as an important potential catalyst for students to view the educational experience as a success. clinical and
theoretical knowledge together bridge the three phases of clinical experience praxis.
The American Heritage Dictionary of the English Language defines
prax-is as “Practical application or exercprax-ise of a branch of learning” (Kleinedler et al., 2006, p. 1379). Brookfield (1990) stated praxis is the principle of “en-suring that opportunities for the interplay between action and reflec-tion are available in a balanced way for students” (p. 50). eyerman and Jamison (1991) identified the salience of multidimensional praxis as a cog-nitive process in social life involving individuals in organizational situ-ations. chinn (2001) defined praxis as, “values made visible through de-liberate action” (pp. 7-8). Penney and Warelow (1999) discussed nursing itself as a form of praxis reflecting tensions in a nexus driven by aes-thetics, discourse, and reflection on theory-practice gaps. in this study, clinical experience praxis was defined as educators’ ability to prepare, offer, and evaluate learning opportunities across phases of learning to meet the students’ needs in the clinical envi-ronment. each phase is unique, but together forms a whole.
Positive clinical educator attri-butes are embedded in each phase of the clinical experience praxis. for ex-ample, in the preclinical phase, edu-cators must display organizational skills, be familiar with the students and their learning needs, become comfortable in the clinical setting, and be cognizant of the clinical course objectives. During the clinical phase, educators’ interpersonal presentation plays a major role in student learn-ing. ideally, educators should be por-trayed as role models with a positive attitude, be a resource for the student, and teach by using a variety of strate-gies. The postclinical phase involves evaluating with students the mean-ing of the day’s clinical experiences using individualized approaches to validate and reinforce learning.
conclusion
attributes assigned to good clini-cal educators were similar to those
attributes identified in prior studies. identification and integration of these clinical nursing educator attributes in the phases of the clinical experience process form the foundation for clini-cal experience praxis. identification of the clinical experience praxis revealed the need for constant review and fre-quent change in teaching strategies in the clinical nursing environment, based on the students’ needs.
Results may be helpful to novice, as well as experienced, educators in the development of educator teaching abilities. Because student learning can be positively affected by the clini-cal experience, educators should look for the best teaching methods in the clinical setting.
areas identified warranting fur-ther research include the topic of paperwork in the clinical setting, specifically researching what kind and amount of paperwork offers the best learning opportunity, (e.g., con-cept maps, care plans), the potential differences in perceptions of gradu-ates from different kinds of nursing education programs, the potential influence prior experience had on the perceptions of the accelerated BsN graduates, and the influence diversity or cultural factors may have on per-ceptions nursing students have about clinical educator attributes.
The clinical experience praxis identified is another important area for additional research, as most prior studies deal with the clinical expe-rience itself but fail to include the preparation or evaluation phases of the experience. studies are needed to examine the phases of the clini-cal experience, their interrelation-ships, educator strategies to transi-tion between phases, and how phases together comprise a unified clinical experience. Research can further test the findings of this study by explor-ing the soundness of this application of educational praxis. finally, further conceptualization of clinical experi-ence praxis as a theoretical construct should be investigated and developed to enhance quality clinical education for students.
references
american association of colleges of Nurs-ing. (1998). The essentials of
baccalau-reate education for professional nursing practice. Washington, Dc: author.
Becker, h.s., Geer, B., hughes, e.c., & strauss, a.L. (1961). Boys in white:
Student culture in medical school.
chi-cago: University of chicago Press. Benor, D.e., & Leviyof, i. (1997). The
de-velopment of students’ perceptions of effective teaching: The ideal, best and poorest clinical teacher in nursing.
Journal of Nursing Education, 36,
206-211.
Bergman, K., & Gaitskill, T. (1990). facul-ty and student perceptions of effective clinical teachers: an extension study.
Journal of Professional Nursing, 6,
33-44.
Brookfield, s.D. (1990). The skillful
teach-er. san francisco: Jossey-Bass.
Brown, s.T. (1981). faculty and student perceptions of effective clinical teach-ers. Journal of Nursing Education,
20(9), 4-15.
Burns, N., & Grove, s.K. (2004). The
prac-tice of nursing research: Conduct, cri-tique, and utilization (5th ed.).
Philadel-phia: saunders.
chinn, P.L. (2001). Peace & power:
Build-ing communities for the future (5th ed.).
sudbury, Ma: Jones & Bartlett. Daniels, M., & DeVos, D. (1996). students’
expectations of clinical teachers.
Ra-diologic Technology, 68, 89-93.
eyerman, R., & Jamison, a. (1991). social movements: a cognitive approach. versity Park: Pennsylvania state Uni-versity Press.
flagler, s., Loper-Powers, s., & spitzer, a. (1988). clinical teaching is more than evaluation alone! Journal of Nursing
Education, 27, 342-348.
Gignac-caille, a.M., & Oermann, M.h. (2001). student and faculty perceptions of effective clinical instructors in aDN programs. Journal of Nursing
Educa-tion, 40, 347-353.
Gillespie, M. (2002). student-teacher con-nection in clinical nursing education.
Journal of Advanced Nursing, 37,
566-576.
hergenhahn, B.R. (1988). An introduction
to theories of learning (3rd ed.).
engle-wood cliffs, NJ: Prentice-hall. Jacobson, M.D. (1966). effective and
inef-fective behavior of teachers of nursing as determined by their students.
Nurs-ing Research, 15, 218-224.
Johnsen, K.O., aasgaard, h.s., Wahl, a.K., & salminen, L. (2002). Nurse educa-tor competence: a study of Norwegian nurse educators’ opinions of the impor-tance and application of different nurse educator competence domains. Journal
of Nursing Education, 41, 295-301.
Kleinedler, s.R., spitz, s.i., anderson,
B., fortson, B.W., Pratt, c., shonthal, h., et al. (eds.). (2006). The American
Heritage dictionary of the English language (4th ed.). Boston:
houghton-Mifflin.
Knox, J.e., & Mogan, J. (1985). important clinical teacher behaviours as perceived by university nursing faculty, students and graduates. Journal of Advanced
Nursing, 10, 25-30.
Kotzabassaki, s., Panou, M., Dimou, f., Karabagli, a., Koutsopoulou, B., & iko-nomou, U. (1997). Nursing students’ and faculty’s perceptions of the char-acteristics of ‘best’ and ‘worst’ clinical teachers: a replication study. Journal
of Advanced Nursing, 26, 817-824.
Li, M.K. (1997). Perceptions of effective clinical teaching behaviours in a hos-pital-based nurse training programme.
Journal of Advanced Nursing, 26,
1252-1261.
Mogan, J., & Knox, J.e. (1987). character-istics of ‘best’ and ‘worst’ clinical teach-ers as perceived by univteach-ersity nursing faculty and students. Journal of
Ad-vanced Nursing, 12, 331-337.
Nehring, V. (1990). Nursing clinical teach-er effectiveness inventory: a replication study of the characteristics of ‘best’ and ‘worst’ clinical teachers as perceived by nursing faculty and students. Journal
of Advanced Nursing, 15, 934-940.
O’shea, h.s., & Parsons, M.K. (1979). clinical instruction: effective and inef-fective teacher behaviors. Nursing
Out-look, 27, 411-415.
Penney, W., & Warelow, P.J. (1999). Under-standing the prattle of praxis. Nursing
Inquiry, 6, 259-268.
Pine, G.J., & Boy, a.V. (1977). Learner
centered teaching: A humanistic view.
Denver, cO: Love.
Rauen, K.c. (1974). The clinical instructor as role model. Journal of Nursing
Edu-cation, 13(3), 33-40.
Reilly, D.e., & Oermann, M.h. (1992).
Clinical teaching in nursing education
(2nd ed.). New York: National League
for Nursing.
sieh, s., & Bell, s.K. (1994). Perceptions of effective clinical teachers in associate degree programs. Journal of Nursing
Education, 33, 389-394.
strauss, a., & corbin, J. (1990). Basics of
qualitative research: Grounded theory procedures and techniques. Newbury
Park, ca: sage.
Wiseman, R.f. (1994). Role model behav-iors in the clinical setting. Journal of
Nursing Education, 33, 405-410.
Wolf, Z.R., Bender, P.J., Beitz, J.M., Wieland, D.M., & Vito, K.O. (2004). strengths and weaknesses of faculty teaching performance reported by un-dergraduate and graduate nursing stu-dents: a descriptive study. Journal of
